Basic Information
| Provider Information | |||||||||
| NPI: | 1245270222 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ELLIS | ||||||||
| FirstName: | JESSICA | ||||||||
| MiddleName: | LAINE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1648 | ||||||||
| Address2: | |||||||||
| City: | EUGENE | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974401648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412424812 | ||||||||
| FaxNumber: | 5412842038 | ||||||||
| Practice Location | |||||||||
| Address1: | 1435 G ST | ||||||||
| Address2: | |||||||||
| City: | SPRINGFIELD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 974774113 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5412424812 | ||||||||
| FaxNumber: | 5412424813 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 12/04/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QS0010X | MD172850 | OR | Y | Allopathic & Osteopathic Physicians | Family Medicine | Sports Medicine |
ID Information
| ID | Type | State | Issuer | Description | 500694329 | 05 | OR | MEDICAID |